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- Volume 19, Issue 1, 2013
Southern African Journal of Anaesthesia and Analgesia - Volume 19, Issue 1, 2013
Volume 19, Issue 1, 2013
South African Society Of Anaesthesiologists : practice guidelines : 2012 revision : SASA practice guidelines 2012Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 1 –42 (2013)More Less
Since the publication of the first SASA Practice Guidelines by the South African Society of Anaesthesiologists (SASA) in 1987, the Society has continued to expand its involvement in the practice of anaesthesia locally, and in the southern African, African and international arenas. The SASA Practice Guidelines were revised in1990, 1999 and 2006, and the current fifth revision aims to build further on the principles laid down then, while aligning the content with international standards for anaesthetic practice.
Author Christina LundgrenSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
A recent week-long course on South African health law has inspired this editorial. Many laws and acts govern the way in which anaesthesia is practised, both in the public and private sectors. These include the Constitution, the National Health Act, the Health Professions Act, the Consumer Protection Act, the Children's Act, the Mental Health Care Act, and for those involved in obstetrics and gynaecology, the Choice on Termination of Pregnancy Act.
Author J. F. CoetzeeSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 8 –10 (2013)More Less
Pain is now regarded as the "fifth vital sign" and pain relief to be a basic human right. Patient-controlled anaesthesia (PCA) is effective because it enables self-titration to individual requirements. PCA is perceived to be inherently safe because of the lockout interval, and because sedation purportedly stops the patient from pressing the button. Nevertheless, because of respiratory depression, increasing numbers of adverse events are serious cause for concern. Respiratory depression comprises three components: central respiratory depression, airway obstruction and sedation. Together, these effects result in opioid-induced respiratory impairment (OIVI). Strategies for safety improvement include an understanding of opioid pharmacokinetics and pharmacodynamics, appropriate dosing regimens, establishing guidelines and written orders, appropriate monitoring and record-keeping, staff training for PCA competency, preoperative patient education and oxygen administration when appropriate, e.g. sleeping patients. Initial postoperative analgesia should be established personally by the attending practitioner who should titrate small doses of opioid to the desired effect. It is emphasised that counting breathing rates is an unreliable index of OIVI is that the quality of breathing should be assessed, and that sedation occurs before OIVI, is clinically obvious. Therefore, monitoring and recording a sedation score at regular intervals is essential. During opioid administration, sedation should be regarded as the "sixth vital sign".
Author A. G. ParrishSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
For more than a decade, systematic reviews have questioned the value of colloids in fluid resuscitation. A Cochrane review that was updated in early 2012 found no mortality advantage relative to crystalloids across a range of conditions for gelatins [risk ratio (RR) 0.91, 95% confidence interval (CI): 0.49-1.72], albumin (RR 1.01, 95% CI: 0.93-1.10), or hydroxyethyl starch (RR 1.10, 95% CI: 0.91-1.32.) Subsequent to that review, two further high-quality randomised controlled trials [Crystalloid vs Hydroxyethyl Starch Trial (CHEST) and Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial also failed to demonstrate a mortality benefit and raised concerns about renal harm. This overview looks at the evolution of evidence on colloid use. The issue of what constitutes sufficient evidence to pronounce on lack of benefit is raised, and two further EBM conundrums are explored. Firstly, is it appropriate to continue collecting patient data on harms in the absence of clear evidence of benefit? Secondly, in the absence of convincing mortality advantages for pooled groups of patients with disparate illnesses, is it appropriate to continue subgroup analyses that seek specific groups who may benefit? The roles of biological plausibility and surrogate end-points in guiding decision-making are explored, and ways of using apparently negative evidence to change standard practice addressed.
Author K. BesterSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 14 –17 (2013)More Less
Although between 50% and 85% of children may have a heart murmur, most heart murmurs are innocent. Murmurs can occur because of children's high cardiac output and small vessels, branching at acute angles, which promote turbulent flow. Innocent murmurs can be described according to seven characteristics, but not all murmurs adhere to these rules. There are seven different types of innocent murmurs. An innocent murmur can often be diagnosed by taking a history and conducting an examination. An electrocardiogram is helpful in assessing left ventricular mass if aortic stenosis (AS) or hypertrophic cardiomyopathy (HOCM) is anticipated. If uncertainty exists, the differential diagnosis should guide decision-making. If a high-risk lesion, such as an AS or HOCM is anticipated, it should be assessed first, while a more benign lesion, such as an atrial septal defect, could be evaluated by a cardiologist after surgery. The type of surgery is also a deciding factor. Any child under one year of age has a much higher risk of having pathology which may be severe, and will need to be referred before surgery. Endocarditis prophylaxis and the risk of air emboli should always be considered.
Author R. M. GraySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 20 –23 (2013)More Less
Paediatric muscle disorders have significant implications for anaesthetists. Their effects extend beyond skeletal muscle and manifestations in other organ systems are frequently seen; in addition, adverse reactions to anaesthetic drugs may result in fatality if unrecognised or inadequately treated. In the past, it was thought that muscular dystrophies and myopathies put a patient at increased risk of malignant hyperthermia, however, the link between these conditions has largely been dismissed and other anaesthetic catastrophes, such as anaesthesia-induced rhabdomyolysis, are now recognised. Undiagnosed muscle disorders put children at risk of experiencing adverse reactions to anaesthesia. A high index of suspicion should be exercised during preoperative review to facilitate anaesthetic choices and guide intraoperative management.
Author G. S. WilsonSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 24 –26 (2013)More Less
Ketamine is one of the oldest intravenous anaesthetic agents that is still in clinical use. Its unique mechanism of action and interaction with a variety of different receptors has sparked renewed interest in its use in a host of alternative clinical settings. This review briefly discusses the pharmacology of ketamine and ketamine's potential use in major depressive illness, opioidinduced acute tolerance and as a potential neuroprotective agent.
Author R. A. DyerSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 29 –32 (2013)More Less
Recent years have seen considerable sophistication in the practice of obstetric anaesthesia in the developed world. Important areas include regional anaesthesia in labour, regional anaesthesia for caesarean section (CS), categorization of the urgency of CS, and clearer definition of fetal indications for CS. The physiological basis for management of spinal hypotension is now well understood. Regional anaesthesia for patients with preeclampsia is established, and is rapidly developing in those with cardiac co-morbidities. Maternal awareness during general anaesthesia for CS has been considerably reduced. A better understanding of the pharmacology of oxytocic drugs has facilitated the management of obstetric haemorrhage. However, anaesthesia-related maternal morbidity and mortality in South Africa remains unacceptably high, and a major effort, including the development of a Special Interest Group, is necessary to address the specific problems in obstetric anaesthesia in our country.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 34 –37 (2013)More Less
Of all perioperative complications, respiratory difficulties represent the greatest cost to the healthcare system. Patients undergoing cardiac, thoracic, gastrointestinal and orofacial surgery are particularly at risk. However, the highest 30-day mortality for pulmonary complications follows abdominal surgery. Patients with chronic obstructive pulmonary disease (COPD), decreased preoperative SpO2, and recent respiratory infections are at increased risk. Epidural analgesia improves outcomes in thoracic, abdominal and orthopaedic patients. Chest physiotherapy, including respiratory muscle training and smoking cessation, can reduce risks in high-risk patients. Intraoperative management strategies in patients with COPD need to consider the potential presence of CO2 retention, right ventricular dysfunction, bullae and auto-positive end-expiratory pressure.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 38 –40 (2013)More Less
This lecture will discuss the risks that are associated with the management of patients with anterior mediastinal masses. A plan for risk stratification and preoperative evaluation of such patients will be developed. The indications and available options for anaesthetic management will also be reviewed. Myths about the perioperative management of such patients will be highlighted, specifically flow-volume spirometry and standby cardiopulmonary bypass.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 42 –50 (2013)More Less
Nonphysiological ventilation in healthy lungs induces acute lung injury (ALI). Protective lung ventilation in patients with ALI improves outcome. Protective lung ventilation in noninjured lungs and in the absence of a primary pulmonary insult may initiate ventilation-induced lung injury (VILI), as evidenced by inflammatory markers. VILI has important implications that are remote to the lungs and may be associated with significant morbidity and mortality. Volatile anaesthetics can have a lungprotective effect. Excess fluids may contribute to perioperative lung injury. Anaesthesiologists manage a heterogeneous group of patients in the perioperative period, from patients with healthy lungs and patients with at-risk lungs through to patients with established ALI. More patients are at risk for ALI during surgery than previously thought. Appropriate perioperative management may prevent or ameliorate this lung injury. Although evidence is lacking from randomised controlled trials, applying protective ventilatory strategies seems to be a reasonable approach, based on the current understanding of mechanical ventilation and lung injury.
Author E. H. WelchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 52 –54 (2013)More Less
Airway surgery provides a unique challenge in that the airway is shared between the anaesthetist and surgeon. Patients may experience airway obstruction, often at extremes of age, following aspiration of a foreign body by the young or tumour-related impediments in the elderly which are complicated by smoking-related heart and lung disease. The threat of hypoxia, retained carbon dioxide and complete airway obstruction is present pre-, intra- and postoperatively.
Author S. X. ColesSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 56 –58 (2013)More Less
Recovery after anaesthesia must be monitored carefully, and patients should be assessed before they are discharged to the ward or some other area where they are less likely to receive the same level of care. While the anaesthetist is responsible for his or her patient until he or she is discharged from the recovery room, the decision to make the release is usually delegated to a responsible trained nurse. Therefore, strict discharge criteria are essential.
Preoperative B-type natriuretic peptide risk stratification : do postoperative indices add value? : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 60 –65 (2013)More Less
Objectives: It is unclear if there is value in measuring postoperative B-type natriuretic peptide (BNP) in patients risk-stratified using preoperative BNP.
Design: Prospective observational study.
Setting and subjects: Patients undergoing vascular surgery at Inkosi Albert Luthuli Hospital, Durban. Data on intraoperative risk predictors, i.e. the nature of the surgery, number of transfused red blood cell units and the duration of surgery, were collected. Preoperative and postoperative BNP, electrocardiographic and troponin I monitoring were performed. Multivariable analysis was conducted to identify independent predictors of adverse cardiac events and then tested using reclassification statistics.
Outcome measures: The composite of troponin elevation within the first three postoperative days and all-cause mortality within 30 days of surgery.
Results: In 149 eligible patients, the study outcome occurred in 27 patients and was independently predicted by red blood cell (RBC) transfusion [odds ratio (OR) 1.8, 95% confidence interval (CI):1.08-3.08] and postoperative ischaemia (OR 7.1, 95% CI: 2.78-18.2). Postoperative BNP was not statistically significantly associated with the outcome (OR 2.1, 95% CI: 0.81- 5.45, p-value = 0.13). In patients who were risk stratified using preoperative BNP, postoperative ischaemia appropriately improved risk classification overall (a net reclassification improvement of 82.5%, p-value < 0.001).
Conclusion: RBC transfusion and postoperative ischaemia, but not postoperative BNP, were independent predictors of the composite outcome of all-cause mortality or postoperative troponin elevation. Postoperative ischaemia improved overall risk classification.
Infection control in anaesthesia in regional, tertiary and centralhospitals in KwaZulu-Natal. Part 1 : unsafe injection practicesamong anaesthetists : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 68 –70 (2013)More Less
Objectives: Unsafe injection and vial usage practices, including the reuse of needles and syringes for different patients, is one of the leading causes of the iatrogenic spread of blood-borne diseases. A study was conducted to determine the prevalence of the reuse of single-patient syringes and spinal fentanyl ampoules among anaesthetists at regional, tertiary and central hospitals in KwaZulu-Natal.
Method: All hospitals that are classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited. All encountered anaesthetists, regardless of rank or experience, were invited to complete a simple questionnaire in confidence.
Results: Ninety-one anaesthesiologists and anaesthetic practitioners completed the questionnaire. Thirteen (14%) of the anaesthetists admitted to reusing syringes on different patients. Seventeen (19%) of the anaesthetists admitted to reusing syringes on different patients after they had changed the needle or set. Fifty-seven (63%) practitioners acknowledged reusing single-use fentanyl ampoules for multiple patients.
Conclusion:The reuse of single-use syringes and single-use vials for multiple patients is an unacceptable practice. This issue should be urgently addressed.
Anaesthetic management of a rare variety of cardiac myxoma for emergency decompression laminectomy : case studyAuthor S. Yemul-GolharSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 71 –72 (2013)More Less
Primary cardiac tumours are rare. Right ventricular myxomas and a combination of right atrial and ventricular myxomas are very rare. A patient with myxoma has several problems, including haemodynamic compromise in a particular position, embolisation and hypoxaemia because of low output and possible shunts. All of these problems increase the risk of having anaesthesia. We present a case of a rare combination of right atrial and ventricular myxoma. A patient presented with sudden onset paralysis of both limbs and was posted for emergency decompression laminectomy.
Perioperative care of a child with Ullrich congenital muscular dystrophy during posterior spinal fusion : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 73 –76 (2013)More Less
Ullrich congenital muscular dystrophy (UCMD) is one of a group of disorders known as congenital muscular dystrophies. Severe hypotonia and early diaphragmatic involvement may lead to respiratory failure early in the disease process. We present the case of a nine-year-old with UCMD who required operative intervention for progressive scoliosis. In these patients, anaesthetic issues relate to difficulties with endotracheal intubation, as well as the potential for postoperative respiratory failure, given early diaphragmatic involvement. As with other types of muscular dystrophy, succinylcholine is absolutely contraindicated, while a prolonged effect may be seen following routine doses of nondepolarising neuromuscular blocking agents. Additional perioperative concerns relate to the surgical procedure primarily, including tailoring the intraoperative anaesthetic to facilitate neurophysiological monitoring, as well as the use of techniques to limit intraoperative blood loss. The perioperative management of patients with UCMD is discussed and options for intraoperative anaesthetic care are reviewed.
Elective use of intra-aortic balloon pumping during Whipple's procedure in a patient with ischaemic heart disease : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 77 –79 (2013)More Less
A 61-year-old man with diabetes who presented with carcinoma of the head of the pancreas was detected to have severe coronary artery disease. Coronary artery bypass grafting was advised. In view of the urgent nature of the abdominal surgery, resection of the malignancy was carried out prior to coronary revascularisation, after placement of an intra-aortic balloon pump (IABP) following induction of anaesthesia to prevent perioperative myocardial ischaemia. The use of an IABP in a noncardiac setting is not well established. Only 16 cases have been reported. To the best of our knowledge, this is the second documented case of the use of elective IABP during Whipple's procedure.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 80 –81 (2013)More Less
In this article, we describe a critical incident which occurred in our operation theatre involving an anaesthesia machine. The oxygen flowmeter broke into three pieces and completely shut down the oxygen flow during anaesthesia. A brief review of the literature on equipment failure during anaesthesia is also given.